Semaglutide/Tirzapetide Intake Form
  • Online Visit

    Welcome
  • Start with the Basics

    This information helps your healthcare provider determine if you’re eligible for treatment.
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  • Format: (000) 000-0000.
  • By giving us your phone number and continuing, you agree that Medicology may send text messages to your phone number and for any other lawful purpose related to your Medicology account and your use of our services, including order confirmations, shipment notifications, and messages from your provider. Message and data rates may apply. Message frequency varies. Reply HELP for help. Reply STOP

  • Let's Talk about your health

    Tell your healthcare provider about your history with weight management, eating habits, and your level of physical activity. You must be honest and respond as accurately as possible.
  • Please enter your height and weight.

    Height and weight are an important part of a thorough health history and can impact your recommended course of treatment. BMI >30 Requirement or BMI >27 with other health conditons
  • Select any method of weight loss you have tried in the past.

  • LET’S TALK ABOUT YOUR HEALTH

    Tell your healthcare provider about your overall health to see if GLP-1s are an appropriate treatment for you. It’s important that you are honest and respond as accurately as possible.
  • Telehealth Services

    Telehealth Informed Consent Informational Sheet

    What is telehealth?

    Telehealth is a way to visit with healthcare providers, such as your physician, nurse practitioner, physician assistant, or mental health therapist from any place, including your home. You don’t physically travel to a clinic or hospital. Telehealth is a way for you to receive care using telecommunications technology to connect you with your healthcare provider. You can do so from any location where you have access to a device and an internet connection.
    You meet with your healthcare provider via an electronic device such as a phone, computer, or tablet by transmitting audio and video.

    Benefits of telehealth

    Virtual visits are growing in popularity. Though in-person office visits may be necessary in certain cases, there are many benefits of telehealth care.

    Limited physical contact reduces everyone’s exposure to infectious diseases
    Virtual visits ensure you get health care wherever you are located – at home, at work or even in your car. Virtual visits cut down on travel, time off from work, and the need for childcare. Virtual health care tools can shorten the wait for an appointment.
    Increased access to specialists who may be located far away from your hometown.

    Potential risks for the use of telehealth

    As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
    In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the clinician providing your healthcare via telehealth.Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
    In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information. In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors. You and your healthcare provider will not be in the same room, so it may feeldifferent from an office visit.Your healthcare provider may make a mistake because they cannot examine you as closely as at an office visit. (We do not know if mistakes are more common with telehealth visits.) Your healthcare provider may decide you still need an office visit if they feel that the information obtained via telemedicine was not sufficient to make a diagnosis. The video connection may not work, or it may stop working during the consultation. The video picture or information transmitted may not be clear enough to be useful for the consultation. Therefore, you may be required to go to the healthcare provider’s office. Not all networks are private and secure. It is the responsibility of the patient to ensure that the network and device used by the patient for telehealth services is secure and private.

    Will my telehealth visit be private?

    Telehealth visits are not recorded. Your healthcare provider will take notes as they normally would in our secure electronic medical records system, which is separate from our telehealth technology. If people are near you, private information may be overheard by others. You should be in a private place, so other people cannot hear you. Your healthcare provider will tell you if someone else from their office can hear or see you. The Department of Health uses telehealth technology that is designed to protect your privacy. However, as with any internet-based communication, there is a very small chance that someone could use technology to hear or see your telehealth visit.

    What if I try telehealth and don’t like it?

    You can stop using telehealth any time, even during a telehealth visit. You can always schedule an office visit if you no longer want a telehealth visit.
    Should you choose not to opt for any telehealth or to stop telehealth your future care or treatment will not be affected.

    How much does a telehealth visit cost?

    What you pay depends on your insurance. If you are self-pay, you may be billed for the visit. A telehealth visit will not cost any more than an office visit. If your healthcare provider decides you need an office visit in addition to your telehealth visit, you may have to pay for both visits.

    Do I have to sign this document?

    No. If you are interested in the provision of some health services by telehealth, all you need to do is initial the telehealth consent section on the Initiation of Services form. What does it mean if I initial the consent for telehealth services? You acknowledge that you have read the information in this document. All your questions have been answered. You want a telehealth visit.

  • Your Plan

    Choose Your Preferred GLP-1 Weight Loss Medication
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  • What’s included:

    • Semaglutide or Tirzapetide Kit includes Medication, syringes, alcohol swabs, and a sharps container
    • Personalized treatment plan
    • Ongoing provider support
    • Personal health coaching
  • prevnext( X )
          Compound Semaglutide At-home kit
          $399.00 for each month
            
          Compound Semaglutide 3 months

          Includes Compound Semaglutide for 3 months 

          $999.00 for each three months
            
          Tirzepatide Compound Monthly
          $599.00 for each month
            

          Credit Card Details
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